ASSESSMENT

Subjective:
No Verbal Cues
Objective:
(+) Right Sided
Weakness
(+) Stiffness of
Upper Extremities
(Hard to Mobilize)
(+) Low level of
Muscle Strength

NURSING
DIAGNOSIS
Impaired Physical
Mobility related to
neuromuscular
impairment as
evidenced by body
weakness, stiffness
of upper extremities
and low level of
muscle strength

BACKGROUND
KNOWLEDGE
Impaired Physical
Mobility
Limitation in
independent,
purposeful physical
movement of the
body or of one or
more extremities.
This might be a
result of damage in
the brain
(CVD/CVA).

PLANNING

INTERVENTION

RATIONALE

After 3 hrs of nursing

intervention the
patients relative will
be able to:

1. Assess the
knowledge of
patients relative
about immobility and
implications

1. Giving the
patients relative the
knowledge will help
them to manage her
condition well. To
have effective nursepatient interaction.

Verbalize
understanding
and
demonstrate
techniques on
how to
manage
problem
Participate in
interventions
given

2. Perform physical
activity
independently or
with assistive
devices as needed
3. Teach patients
relative on what
exercises and how
to do exercises that
can help patients
condition
4. Encourage
patients relative to
continue to exercise
the patient
5. Instruct patients
relative in methods
of moving patient
relative to mobility
needs

EXPECTED
OUTCOME
After the 2 hrs of
nursing intervention
the patient is able to:

Verbalize
understanding
and
demonstrate
techniques on
how to
manage
problem

Participate in
interventions
given

2. Assess degree of
mobility produce by
the disease
3. Giving the
patients relative the
knowledge will help
them to manage her
condition well. To
have effective nursepatient interaction.
4. To maintain and
enhance gains in
strength and muscle
control
5. To effectively
assist and help the
patient
6. To prevent patient

6. Ensure side rails

up

ASSESSMENT

NURSING
DIAGNOSIS

BACKGROUND
KNOWLEDGE

PLANNING

INTERVENTION

from possible fall or

accident that might
happen
RATIONALE

EXPECTED
OUTCOME

Subjective:
No verbal cues
Objective:
(+) Wheezing
(+) Shortness of
Breath
(+) Tracheostomy
tube
-(+) Secretions
(+) O2 Therapy on
10.5 L/ Min
Nebulization q6

Ineffective airway
clearance related to
retained secretions
as evidence by
wheezing, shortness
of breath, secretions
in tracheostomy tube
and O2 Therapy
10.5 L/min

The inflammatory
response to infection
causes tissue
edema and exudates
formation in the
lungs, the
inflammatory
response can narrow
and potentially
obstruct bronchial
passages and
alveoli.

After 3 hrs of nursing

intervention the
patient and patients
relative will be able
to:

Maintain
airway
patency
Clear
secretions
Verbalize
understanding
of condition
and
therapeutic
regimen

1. Monitor
respirations and
breath sounds noting
rate and sounds

1. Indicative of
respiratory distress
and/or accumulation
of secretions

2. Suction secretions

2. To decrease
retained secretions

3. Teach patients
relative techniques
on how to manage
condition
4. Provide
information about
the necessity of
expectorating
secretions
5. Position patient
properly ( head of
bed elevated)

3. To help in
managing the
condition
4. To report changes
in colour and
amount in the event
that medical
intervention may be
needed to prevent or
treat infection
5. To prevent
vomiting with
aspiration into lungs

After the 2 hrs of

nursing intervention
the patient is able to:

Maintain
airway
patency

Clear
secretions

Verbalize
understanding
of condition
and
therapeutic
regimen

ASSESSMENT
Subjective:
No verbal cues

Objective:

NURSING
DIAGNOSIS

BACKGROUND
KNOWLEDGE

PLANNING

Impaired Skin
Integrity related to
prolonged bed rest

Prolonged bed rest

causes the skin to
have an allergic
reaction. This will
make the skin feel
itchy and irritated

After 2 hrs of nursing

intervention the
patients relative will
be able to:

Disruption
in the skin
surface of
the right
foot
(+) Bedsores
Left
posterior
foot ,
scattered
formation in
2-5 mm
diameter
(+) Poor
Skin Turgor

Verbalize
understanding
and
demonstrate
techniques on
how to
manage
problem
Participate in
prevention
measures and
treatment
program

INTERVENTION
1. Assess skin,
noting color,
moisture, texture,
temperature; note
erythema, edema,
tenderness.
2. Advise patients to
maintain good skin
hygiene, (ex. Wash
and pat dry
carefully).
3. Teach patients
relative the
importance of
maintaining a clean
and dry skin.
4. Advise patients
relative to follow
medication regimen
(applying topical
cream to wound).
5. Teach patients
relative on how to
monitor his skin
condition (noting if

RATIONALE

EXPECTED
OUTCOME

1. Establishes
baseline providing
opportunity for timely
intervention

After the 2 hrs of

nursing intervention
the patient is able to:

Verbalize
understanding
and
demonstrate
techniques on
how to
manage
problem

Participate in
prevention
measures and
treatment
program

2. Maintaining clean
and dry skin
prevents infection.
3. Giving the
patients relative the
knowledge will help
them to manage her
condition well.
4. Following
medication regimen
will greatly help in
improving the
condition.
5. Giving the patient
the knowledge will
help them to prevent
complications.

there is any changes

in the skin
condition).